Mt Whitney Zone Forums Trip Reports Whitney trip report and AMS cases

Whitney summit 8/8/11 and cases of AMS

This report is done to describe cases of AMS and 1 other medical issue on the trail from Onion Valley/Kearsarge Pass via JMT to Whitney summit 8/8/11.

This report is written from the perspective of my 20th trip from Virginia to High Sierras, and as a mountaineering physician with personal and expedition experience, and as a frequent contributor to this forum. This is for educational purposes.

Our group of 10 from VA were all friends with backpacking experience ranging from minimal to extensive, and high altitude backpacking experience ranging from none (Subjects M and N) to extensive, and ages from 55 to 71. Acclimatization began with 3 nights in Mammoth 7800 ft with day hikes to 10,000 ft. Subject C, Subject N, and myself took low dose Diamox 250 ¼ tab twice daily. All others were offered Rx but declined. On the first day climbing Kearsarge Pass, Subject C developed "an elephant sitting on my head" at 11,000 ft, the same threshold that she had experienced difficulty several times before. She requested a descent, so I escorted her down and drove her back to Mammoth. The group followed "plan B" if this happened, and continued on to the 1st night camp at Kearsarge Lakes, and the 2nd night at the treeline 11,000 ft north of Forester Pass. I rejoined them there with a single day push. I had the single sat phone in the group and now realize we should have had two.

Forester Pass took several hours longer than usual because of snow and new altitude experience for all but 2 of us. We reached Tyndall Creek for camp 3, and Guitar Lake for camp 4. Another group at Guitar Lake had left behind (by herself) a vomiting woman (who was fine when we arrived there) but they were late returning from an expected 10 hr roundtrip of Guitar-summit-Guitar with daybacks only. Our group would be carrying the next day's backpacks to the Trail Crest junction, and after summiting, from there to Trail Camp. Because of our large group's slow morning departures, I recommended an earlier than usual start on summit day - up at 4:00, off at 5:30.

Summit morning began with Subject N having rectal bleeding described as bright red similar to a menstrual period. She had a history of rectal surgery and wondered if the trail diet of nuts, granola, etc, had aggravated her. She came prepared with "light pads" and with good spirits in the face of adversity continued on. Each member of the group (or couples) were allowed to proceed this day and every day at their own pace. Subject M was tired, perhaps a little nauseated, and could not catch a full breath since the afternoon before, but had not informed anyone other than her husband. By the time she reached the summit ridge at 14,000 ft she could not move further. I was in the sweep position and found her sitting with head in hands, a headache rated a "10" and appearing exhausted. She did not appear short of breath at rest, and was coherent. She and her husband began descent, with instructions for rendezvous with the summit party afterwards lower down. .

Now back at Trail Camp, 8 of us were fine, but Subject M was nauseated and rated her headache (with eyes clinched closed) as an "8." With the morale assistance of two other females in the group, I tested her for medical signs of disorientation or ataxia. There were none, so immediate descent was not mandatory. I was concerned that further slow descent for her would be problematic at night, but if we stayed at 12,000 ft there was the threat of worsening of her AMS overnight to complications of AMS. I recommended steroids as a rescue drug, fearing that her severe headache was a forerunner of cerebral edema (it can be) and that continued stay at 12,000 ft kept her in the danger zone. Initially she declined Rx, stating that it was treating the problem with a sledge hammer. I pointed out that she should not consider taking it only for her own medical state, but for the benefit of the whole group who might need to evacuate her tomorrow. She finally agreed, but only to a smaller dose than I recommended.
The next morning I was ready early, and advised her that she and I would begin her descent immediately. She still had headache and nausea, but was dressed. She insisted on carrying her pack. Like most AMS victims I have seen, she did not want to appear to be shirking her share of the work. I grabbed her sleeping bag while others grabbed other gear to lighten her load and we set off, non-stop for the Portal, sipping fluids on the way. At the Portal, she ate a little while the rest of the group caught up and ordered Doug's superb burgers. Her nausea and headache continued overnight after the ride back to Mammoth. The next day her face was visibly bloated and swollen. Some might question if the steroids she was given might have contributed to the facial swelling?. No. She had agreed only to a single and minimal dose of 10 mg prednisone, nowhere near the potency one might ordinarily use with dexamethasone. That low dose and short term usage would not have caused facial edema. She looked much like victims I have seen at more severe altitudes like 20,000 ft. She clearly had had a severe case of AMS that would likely take 48 hrs to resolve. I called to check on her on her way home at the Las Vegas airport and improvement seemed to be following that time frame.


Harvey

Thanks for the informative report, Harvey. With all the talk on the boards now and then about Diamox (and to a lesser extent, Dex), it never even occurred to me that Prednisone might be useful in an AMS situation. Is Prednisone, then, considered both an anti-inflammatory and a steroid, or just one or the other? Living in Ohio (i.e., ragweed country), I usually get an annual prescription of one or two weeks' worth of Prednisone (10 mg pills), which I take once daily during the worst part of the ragweed season, only if needed, and for as short of a duration as needed. Although I have never had any altitude-related problems, I wasn't even aware that these little pills could be helpful should that ever come up. Thanks.

CaT

Prednisone , dexamethasone , Medrol, and some others are all synthetic, pure glucocorticosteroids with far more powerful antinflammatory effects than OTCs like ibuprofen and the other NSAIDs. Most high altitude steroid usage is with dex mainly because it is the most potent and given by injection with really severe cases. They all have the same action and will work. By prescription or MD use only.

Thanks for the report, Harvey.

I am surprised at the number of members experiencing the AMS after that much time.

I assume the bleeding problem resolved.

Great thorough report Harvey.That group has no idea how lucky they were to have an experienced high altitude doctor in their group.The knowledge,experience and ability to acurately diagnose. That armed with appropiated meds is an extraordinary valuable asset.Thanks for sharing the details.Good job as a moutaineer and doctor.

Thanks, Rod. You guys might check some of comments where I posted this on the other forum

Yes I read the comments on the other board. Very interesting read.Enjoyed some good questions and of course Ken another doctor adding his knowledge.Very educational read. Bottom line just like treating patients in our practices everyone is different and everyones case and their S&S are unique for them.There are so many factors to consider to why someone may get AMS or not and what course of treatment is appropiate for that individual.Genetics; Training/conditioning; hydration/over hydration;Proper acclimation;diamox;sleep deprevation;hypoglycemia;overexertion due to pace or too heavy pack.....

Harvey,

Thanks so much for sharing your knowledge of AMS with practical experience. I have found all your postings very informative.

I had an experience this weekend with AMS & migraines and had some questions.

Background:
I met a couple of women on the side of a trail close to 10k. One of the women was experiencing a headache. (All of us where dayhiking and lived at sea level) I suggested it might be AMS and suggested they start heading down the trail.

The woman that wasn't feeling well mentioned she gets headaches frequently and even has migraines at sea level. In fact, she had some medication for her migraines and was considering taking one of her pills. (She and her hiking partner agreed to wait 20 mins and start down if no improvement)

Questions:
Has there been any studies to indicate people that have a history of migraines are more susceptible to AMS? Would migraine meds help with AMS? I know you have stated it should be considered AMS unless proven otherwise. What would be some criteria to determine the difference between an AMS headache & a migraine? Is there a difference between AMS & migraines?

Wazzu

Interesting timing. While not directly on point, this article from the New York Times yesterday on migraines and hydration seems apropos.... New York Times article on migraines

Waz, thanks for the kind words. Migraines and AMS may have similarities in that cerebral blood vessel dilatation or the opposite constriction may be a result of the high altitude trigger on one hand, and the migraine unknown trigger on the other.But AMS has the additional causation in that simple AMS headache taken to its farthest extreme is brain swelling (High Altitude Cerebral Edema or HACE) . So there really is a difference in pathophysiology.

I do not know if a migraine sufferer at altitude can always tell if their headache is one or the other.The worst headache I personally ever had at high altitude was a day flat on my back at 19, 000ft. It was as bad as the time I had viral meningitis. So I have empathy for anyone with a bad headache.

Harvey

PS So water is the newest Rx du jour for migraines? Wish it was that simple!